**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to prevent accidents and hazards related to smoking safety precautions, for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of a 44 residents on the facility residents who smoke list. The facility failed to ensure the safety of all 229 residents in the facility as a result of the failure. On 9/22/23 at 5:11 p.m. Resident #61 was found smoking (alleged) marijuana in an unauthorized smoking area by the Nursing Home Administrator. On 10/21/23 at 4:03 a.m. the facility's fire alarm was triggered when Resident #102, while smoking in her room unsupervised, caused her mattress, privacy curtain, and oxygen concentrator to catch on fire. Staff extinguished the fire, the fire department and emergency medical services (EMS) were called, and residents on the same hallway as Resident #102 were evacuated. Resident #102 sustained a 1st degree burn to her left forearm and shortness of breath due to smoke inhalation. On 10/21/23 Resident #102 was transferred to the hospital for evaluation and treatment. On 10/24/23 at 4:59 p.m. Resident #61 was found by the Nursing Home Administrator smoking in a non-smoking area with his oxygen tank on his wheelchair. Observations conducted on 11/27/23, 11/28/23, and 11/29/23 revealed residents had unsecured smoking materials on their person, were seen lighting other residents' cigarettes on the smoking patio in front of the facility staff and were smoking in non-smoking areas on the facility property. The facility had no effective process in place to ensure residents received smoking safety devices. The facility lacked a functioning process for supervised smoking times. The likelihood of serious physical harm or death to all 229 residents in the facility as a result of the facility's failure to ensure the safety, supervision, and prevention of accidents and hazards resulted in findings of Ongoing Immediate Jeopardy as of 9/22/23. Findings included: On 11/28/23 from 8:56 a.m. to 9:47 a.m. smoking observations were conducted on the main smoking patio of the facility. Staff O, Certified Nursing Assistant (CNA), was present for the observations. A total of nine residents were observed entering and leaving the main smoking patio during the observations. Staff O, CNA, stated he was the smoking aide but he was not the usual smoking aide. The following observations were noted: At 8:56 a.m. Resident #114 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:10 a.m. he left the smoking area and did not turn in his cigarettes or lighter to the smoking aide. At 8:59 a.m. Resident #96 pulled a cigar pack and a lighter out of his shirt pocket and lit his cigar and placed the package and lighter back in his shirt pocket. At 9:00 a.m. Resident #162 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:08 a.m. he left the smoking patio and did not turn in his cigarettes and lighter. At 9:16 a.m. Resident #102 asked Resident #61 (another resident on the smoking patio) if he could light her cigarette; he said yes, self-propelled his wheelchair closer to Resident #102 and lit her cigarette. Staff O, CNA, was on the smoking patio at this time. At 9:17 a.m. Resident #61 left the main smoking patio with his lighter in his hand. At 9:07 a.m. Resident #198 pulled a pack of cigarettes and lighter out of his shirt pocket, lit his cigarette, and placed them back in his shirt pocket. At 9:14 a.m. he pulled out an electronic cigarette and held it in his hand. At 9:37 a.m. he put his electronic cigarette back in his shirt pocket and left the main smoking patio. Staff O, CNA, held the door open for the resident to exit smoking patio. Resident #198 did not return his smoking materials prior to exiting the smoking patio. At 9:03 a.m. Resident #131 pulled a pack of cigarettes and a lighter out of her pocket and lit her cigarette. At 9:11 a.m. she left the smoking patio and did not turn in her cigarettes or lighter. At 9:17 a.m. she returned to the main smoking patio and pulled out a pack of cigarettes and a lighter out of her jacket pocket and lit her cigarette. At 9:20 a.m. Resident #131 was observed to have lit Resident #188's cigarette with Staff O, CNA, present in the main smoking patio. Resident #188 returned to his chair on the smoking patio. Resident #188 was observed to have black and orange stains on his right pointer finger, right middle finger, and right thumb. Resident #188 said he had those stains from smoking: it's nicotine. The resident was observed to be smoking his cigarette without an apron on and the ash tray in his lap. At 9:30 a.m. Resident #188 left the smoking area. At 9:34 a.m. Staff O, CNA, held the smoking patio door open as Resident #131 left the main smoking patio and she did not turn in her smoking materials. At 9:18 a.m. Resident #324 pulled out a pack of cigarettes and a lighter from his pants pocket and lit his cigarette. At 9:24 a.m. he left the smoking area and did not turn in his cigarettes or lighter to Staff O, CNA. The resident was assisted out of the main smoking patio door by Staff O, CNA. At 9:23 a.m. Resident #162 returned to the main smoking patio and pulled a cigarette pack and a lighter out of his pants pocket and lit his cigarette in front of Staff O, CNA, and put his lighter and cigarettes back in his pocket. At 9:33 a.m. Resident #162 left the main smoking patio pushing Resident #102 in her wheelchair. Staff O, CNA, opened the main smoking patio door to escort them out. Resident #162 did not turn in his smoking materials. At 9:27 a.m. Resident #184 pulled a cigarette pack and a lighter out of his jacket pocket and lit his own cigarette. At 9:47 a.m. he left the smoking patio and did not turn in his smoking materials. An interview was conducted on 11/28/23 at 9:41 a.m. with Staff O, CNA. He said, this is where we store 'some' of the cigarettes, he opened the smoking cart, and there was a total of 20 boxes with names and numbers on them. (Photographic evidence obtained). Review of the facility's Resident Smokers List, undated, revealed there were 44 residents in the facility who smoke. On 11/28/23 at 9:45 a.m. an interview was conducted with Staff K, Activities Director (AD) and Staff O, CNA. Staff K, AD, came to the smoking patio and stated the process for obtaining and stocking the cigarettes in the smoking cart was activity staff's responsibility. Staff K, AD, and Staff O, CNA said residents were supposed to ask for their cigarettes, and get their cigarettes from the locked smoking cart from their personal drawer. They stated, they are supposed to light the residents' cigarettes for them. Staff K, AD said all the residents who smoke were recently educated on the smoking policy. Maybe last month. We can ask them [the residents who smoke] for their smoking materials and some of them will give them up, but most of them will not and we can't force them to give it to us. On 11/28/23 at 8:58 a.m. through 11/28/23 at 9:47 a.m. Staff O, CNA did not attempt to ask residents for their smoking materials prior to exiting the main smoking patio. Staff O, CNA did not attempt to intervene when residents were lighting other residents' cigarettes. Throughout the observation it was observed there were 2 smoking aprons hanging up in the middle of the main smoking patio not in use. The aprons were white and well kept. A resident council meeting was held on 11/28/23 at 10:00 am with eight members of the resident council including the Resident Council President. During the meeting the residents expressed the facility has not done anything about residents smoking in their rooms. The residents said at least eight to nine residents are smoking in their rooms and the facility is not doing anything about it. The residents said they can't go to the courtyard (non-smoking area) because of the residents who smoke. They stated about three weeks ago a resident caught on fire. They stated the facility does nothing about it and the Administrator is aware. The members stated the AD and staff try very hard, but the issue is the residents that go to the store on their own and hide the smoking materials. They stated the floor staff need to do a better job. They stated they would like to go to the courtyard. They said one resident smokes weed so they took his oxygen away. They stated residents smoke reefer in front of other residents and there is no respect for others. The residents said there was a designated area outside for the residents who smoke and a separate area outside for the residents who don't smoke, but the smoking residents take over all areas. On 11/29/23 at 9:59 a.m. an interview was conducted with Staff O, CNA. He said, We had two people who needed a smoking apron on yesterday [11/28/23], one of them you met yesterday, [Resident #188], I asked him if he can put on his apron, and he told me 'No, I don't need it' so that's why I was keeping close to him. After that, the Activities Director talked to him, and he wore his apron the rest of the day. I knew he needed an apron because the Activities Director told me. He and another guy needed them. We can go to the Activities Director if we need something or have a question, because I don't normally do the smoking. An interview was conducted on 11/29/23 at 9:14 a.m. with Staff DD, Activities Assistant. She said, normally she was the one who comes and does the smoking during the smoking times but since the state surveyors were here, the AD had her out on the smoking patio for eight hours a day and administration said she has to do this until the state surveyors leave. During the interview Resident #188 was observed to have a smoking apron on with his ash tray in his lap and ashes on his apron. Staff DD, Activities Assistant said, I know [Resident #188] needs an apron because you see his fingers are brown because he smokes his cigarettes till the end, and he shakes so he needs the apron. I just know what the residents need by looking at them and I am familiar with them because I used to be their CNA. We do not have a book or anything that says what the residents need during smoking, you can just tell. An interview was conducted on 11/29/23 at 4:55 p.m. with Staff DD, Activities Assistant. She said, I used to do just half hour increments for smoking, not all eight hours. At 4:00 p.m. today I had 35 smokers. This is the only smoke area for residents. Those who LOA [leave of absence] don't need supervision. If cigarette and lighter drawer storage is empty the resident is keeping their lighters and cigarettes. An interview was conducted on 11/29/23 at 5:29 p.m. with the Nursing Home Administrator (NHA). He said, The smoking times are posted on the door. You may have noticed that I have had someone out there all day. We have a lot of residents here that are non-compliant, and the smokers are saying that they are smoking in non-smoking areas because no one is out there for them to smoke during the smoking times, which is not true. So, I am trying something new for them, starting mid last week, a staff member stays out there instead of coming just for the smoke times. At first there was a CNA from each unit doing the smoking times but then I noticed that the CNAs will be busy during that time or the CNAs have to leave the floor to go do the smoking times so I incorporated the activities staff in it but then I noticed that the activities staff will just get done with an activity and it will take them two to three minutes to get to the smoking patio and the residents' excuse was staff weren't there on time and that is why they are going to the courtyard to smoke. So, now I have someone scheduled at the smoking patio from 9:00 a.m. to 7:00 p.m. and it should be an activities staff member on the smoking patio. The NHA provided the facility's Designated Smoke Times posted on the door of the smoking patio and said The posting is wrong. From 6:30 p.m. to 7:00 p.m. a CNA from South [NAME] unit is not scheduled to be on the smoking patio, the activities staff are still scheduled to be out on the smoking patio. Then from 9:00 p.m. to 9:30 p.m. a Northwest unit CNA is scheduled to be on the smoke patio and 11:00 p.m.-11:30 p.m. a Central unit CNA is scheduled to be on the smoke patio. The 3:00 p.m.-11:00 p.m. nurse assigns a CNA to the smoking patio, and it is put on the assignment board. Review of the Designated Smoke Times ALL UNITS posting provided by the NHA from the main smoking patio door revealed the following: 9:00AM-9:30AM (ACT) [Activities] 11:00AM-11:30AM (ACT) 1:00PM-1:30PM (ACT) 4:00PM-4:30PM (ACT) 6:30PM-7:00PM (SW) [Southwest] 9:00PM-9:30pm (NW) [Northwest] 11:00PM-11:30PM (CN) [Central] **All Resident Must Comply with Designated Smoking Times and Locations. ** All Residents Must Leave Smoking Materials in Designated Smoke Locker. *All assigned Units/Activities are responsible for taking residents to designated smoking area and monitoring during smoke times. An observation was conducted on 11/29/23 at 5:00 p.m. The AD locked the door of the smoking area and stated the smoking area will be open during the scheduled hours per the designated smoke times posting. On 11/29/23 at 5:48 p.m. the NHA contradicted his previous statement that staff were assigned to be out on the smoking porch continually from 9:00 a.m. to 7:00 p.m. by saying I just reminded everyone of their scheduled times to make sure everyone remembers. He said no one is on the smoking patio now because it's 5:48 . The NHA stopped midsentence, turned around and walked away. On 11/29/23 at 5:52 p.m. the smoking area remained locked. An interview was conducted on 11/29/23 at 5:40 p.m. with Staff FF, CNA. He stated he had done smoking before. He said he knew the residents well and had a good rapport with them. He said Some residents take their cigarettes and lighters to their rooms and others leave them in the box. An interview was conducted on 11/29/23 at 6:00 p.m. with Staff W, CNA. He stated he had done smoking breaks before. He stated I don't know about any aprons; I just go out, they smoke, and I come back in. He also said there had been a couple fires in the building; he just doesn't know which residents they were. 1. A review of the admission Record showed Resident #61 was initially admitted to the facility on [DATE] with diagnoses to include burn of unspecified degree of multiple sites of head, face, and neck, COPD [chronic obstructive pulmonary disease], respiratory failure, major depressive disorder, anxiety disorder, muscle weakness, and lack of coordination. Review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section J, Health Conditions showed Resident #61 had shortness of breath or trouble breathing when lying flat. A review of the Order Summary Report with active orders as of 12/01/23 revealed the following orders: (10/24/23) oxygen 2 liters per minute per nasal cannula as needed for shortness of breath and/or to keep oxygen sats above 92% (concentrator only; no portable oxygen tanks)- every shift for shortness of breath/decreased oxygen saturation related to respiratory failure, unspecified whether with hypoxia or hypercapnia, COPD with acute lower respiratory infection, and no tanks in the smoking courtyard and (06/12/23) may go LOA without a responsible party. The Treatment Administration Record for October 2023 showed oxygen 2 liters per minute per nasal cannula as needed for shortness of breath with a start date of 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record also showed oxygen 2 liters per minute via nasal cannula as needed for shortness of breath with a start date of 10/21/23 and discontinued on 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record for October 2023 showed an order for oxygen 2 liters per minute every shift with a start date of 06/23/23 and discontinued on 10/13/23. Oxygen was administered each day and every shift. The Weights and Vitals Summary for oxygen saturations showed the last oxygen saturation was checked on 09/13/23 while the resident was on oxygen via nasal cannula. Review of a Progress Note dated 10/24/23 revealed Resident #61 was witnessed smoking in a non-smoking area with oxygen tank on wheelchair. The resident had a history of noncompliance with smoking. He was to only use a concentrator for Oxygen supplementation. No more portable oxygen tanks to be given for safety purposes due to resident's noncompliance. Review of a Progress Note dated 09/22/23 revealed the Reesident #61 was smoking (alleged) marijuana in an unauthorized area of the facility. The resident was informed of the facility smoking policy and told if he does it again, he will have to transfer to another facility. The Smoking Evaluation dated 10/21/23 showed Resident #61 used tobacco/nicotine products. He smoked cigarettes. The resident had the cognitive ability to smoke safely, physical dexterity to smoke safely, visual ability to smoke safely, and had the physical ability to smoke safely. The evaluation showed Resident #61 was able to light a cigarette safely with a lighter, he smokes safely, he utilizes ashtrays safely and properly. The resident was able to extinguish the cigarette safely and completely when finished smoking, communicate the reason oxygen must always be shut off prior to lighter use, and communicate the risks associated with smoking per the evaluation. Based on the evaluation, Resident #61 must be supervised by staff, volunteer, or family member at all times when smoking. The statement resident need for safe smoking aide was left blank. The resident must request smoking materials from staff. Intervention had been reviewed. Resident/ resident representative / family have been informed of smoking policies/procedures and Care plan has been reviewed/updated were checked. The form was completed by Staff C, Assistant Director of Nursing. The care plan related to smoking initiated 09/22/23 revealed a focus area to include Resident #61 desires to smoke. He had been assessed as able to smoke with supervision. The goal showed the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices through the next review date of 12/14/23. Interventions included accompany resident to designated smoking area and provide supervision. On 12/01/23 at 11:26 a.m., the Director of Nursing (DON) stated Resident #61 was admitted into the facility with burns from smoking while using oxygen. He had COPD and respiration evaluations were done upon admission and oxygen saturations should be monitored one time per day or every shift. The doctor changed the orders for oxygen from scheduled to as needed because Resident #61 goes outside and smokes while wearing the nasal cannula with the oxygen tank on the wheelchair. The staff would have to go out and get him and take him back to his room because he would be noncompliant with smoking. When the doctor changed the order to as needed for the oxygen, she would expect to see oxygen saturations being monitored at least every shift. There should be ongoing monitoring because Resident #61 had an order for oxygen as needed, and he smokes. The DON stated he had an order to monitor oxygen saturations. She confirmed the last oxygen saturation was checked in September. The DON stated that was not her expectation and there could be some negative effects because he was not being monitored as he should be for oxygen saturations. On 12/01/23 at 2:08 p.m., Staff BB, Resident #61's Physician, stated the resident does not want to hear anything you have to say. She last saw him on 10/30/23 and she talked to him about smoking issues. They were concerned about the time he spent on the smoking patio wearing the oxygen with the portable oxygen tank on the wheelchair. She said she discontinued the continuous oxygen but Resident #61 would just put himself on the oxygen when he came back from smoking. 2) Review of Resident #102's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her medical diagnoses include but are not limited to, tobacco use, acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease with (acute) exacerbation, personal history of pulmonary embolism, emphysema, need for assistance with personal care, muscle weakness, essential tremor, metabolic encephalopathy, pleural effusion, cognitive communication deficit, dysphagia, oropharyngeal phase, other specified arthritis, unspecified abnormalities of gait and mobility, chronic pulmonary embolism, anxiety disorder, and major depressive disorder. Review of Resident #102's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 15 out of 15 indicating no cognitive impairments. An interview was conducted with Resident #102 on 11/27/23 at 9:59 a.m. The Resident was observed to be in her room, sitting in her wheelchair on 3 liters of oxygen via nasal cannula. The resident was observed to have a small circular hole with black edges on her upper right thigh of her pants. The resident said her pants came that way. The resident said the staff keep her smoking materials and they stick to the smoking schedule. She said she takes off her oxygen when she smokes, and she does not use an apron when she smokes. Review of Resident #102's Smoking Evaluation dated 10/21/23, completed by Staff C, ADON, revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, does not have the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is not able to light a cigarette safely with a lighter, the resident does not smoke safely (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish a cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the resident is able to communicate the risks associated with smoking. Summary review: Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. Indicate resident need for safety smoking aides: resident must wear smoking apron at all times. Maintenance of smoking materials: Resident must request smoking materials from staff . Additional Comments: Resident refused smoking apron. Review of Resident #102's Resident/Family Tool dated 10/21/23, completed by Staff C, ADON, revealed the identified learner was the Resident. She understands basic information. Her readiness to learn is accepting. There are no barriers to learning. Education Needs safety and smoking policy. Education Record: Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters[sic] and or vape pens). Documentation of Topic, Instruction, and Additional information: Resident educated to the facility smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (e.g., cigarettes, lighters). Resident cannot smoke near any combustible items such as oxygen tanks & concentrators. Informed resident that per smoking evaluation, she meets the requirements for wearing a smoking apron s/t[sic] incident resulting in a fire after she dropped a cigarette. Resident informed that if smoking policy is violated again, she will be subject to discharge. Resident verbalized understanding & agreement with everything, except smoking apron. Resident stated she will only smoke in designated area, but she doesn't want an apron. Resident verbalized understanding of personal safety risks r/t [related to] wearing apron during smoking breaks. Review of Resident #102's physician orders revealed an order with a start date of 8/13/2023 and no end date of Oxygen at 2 liters/minute via- Nasal cannula every night shift for Respiratory Distress. An order started on 11/10/23 without an end date to Cleanse BURN TO LEFT ARM with normal saline--Gently pat dry--Apply Xeroform to wound--Wrap with kerlix--Secure with tape. Change daily on 3-11 shift. Review of Resident #102's November treatment administration record (TAR) revealed the order was completed as ordered. Review of Resident #102's Narrative Nurses note dated 10/21/23 at 2:01 p.m. revealed, At around 0403 [4:03 a.m.] Smoke alarm sounded. Writer [sic] witnessed smoke and fire in resident's room. Resident was evacuated along with others while code red and 911 were called. Fire was put out with fire extinguisher. Police and fire department arrive [sic] and assisted staff member to evacuate the wing. Per nurse, Resident has burn to her left upper extremity and complaining of difficulty breathing s/p [status post] smoke inhalation. Resident left the facility with O2 [oxygen] via non-re-breather mask with 911. Resident reported to 911 that she was smoking in the room. Assigned nurse to call MD [Medical doctor] and Family member for notification. Review of Resident #102's change in condition dated 10/21/23 revealed At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 110/64, 10/21/2023 05:03 a.m. Position: Sitting l (left)/arm Pulse: P 88, 10/21/2023 4:05 p.m. Pulse Type: Irregular, chronic RR: R 32, 10/21/2023 5:06 a.m. Temp: T 97.6, 10/21/2023 5:05 a.m. Route: Forehead (non-contact) Weight: W 97.0 lb., 10/5/2023 10:27 a.m. Scale: Mechanical Lift Pulse Oximetry: O2 94 %, 10/21/2023 5:05 a.m. Method: Oxygen via Nasal Cannula .Nursing observations, evaluation, and recommendations are Resident was assess for burns due to her mattress burning . A Narrative Nursing note dated 10/21/23 at 5:54 p.m. revealed PT [patient] returned from hospital with new order for Keflex 500 mg daily. On 10/21/23 at 6:00 p.m. the Narrative Nursing note revealed Resident returned to facility from ER [emergency room] at 1738 [5:38 p.m.]. Resident sent out for burns and dyspnea [difficulty breathing] s/p [status post] smoke inhalation from fire incident earlier today. Resident violated smoking policy by smoking in her room w/ [with] oxygen concentrator present, later resulting in a fire. Resident now returning w/ pressure dressing to left forearm and gauze dressing to right posterior forearm. New skin tear noted under the latter dressing. VSS [vital signs stable], but resident was noted to still have some respiratory discomfort. HOB [head of bed] elevated and Nasal Canula [sic] on 2 LPM [liters per minute], which helped alleviate shortness of breath. During Auscultation, breath sounds were noted to be diminished. Apical pulse normal and regular. Resident did verbalize having some pain. Pain medication given by nurse on duty after assessment to ensure safety of narcotic administration. Resident was then educated on smoking policy and the importance of adhering to it. Resident was apologetic and verbalized agreement and consent w/ complying to smoking policy going forward. Informed resident that smoking re-evaluation resulted in her qualifying for a smoking apron during smoking breaks for safety purposes. Resident stated her refusal to wear apron, as she does not agree with its necessity. Resident educated on the benefits of wearing apron while smoking. Resident verbalized understanding of personal safety risks if she does not wear apron but still stated that she will not wear it. Psychology/Psychiatry consult placed for follow up s/p [status post] incident. On call physician notified of resident's return, present status/condition, new dressing to burn, and new order for prophylactic Keflex s/t [sic] to right forearm burns. Resident comfortable and sleeping in her bed at this time. Review of Resident #102's admission Nursing Comprehensive Eval dated 8/4/23 revealed a smoking evaluation to include, the resident uses tobacco/nicotine products, she uses cigarettes (non-electronic), the resident has the cognitive ability to smoke safely, has the visual ability to smoke safely, physical dexterity to smoke safely, and the physical ability to smoke safely. 02b. Resident Observation She is not able to light a cigarette safely with a lighter. She smokes safely, she utilizes the ash tray safely and properly. She is able to extinguish a cigarette safely and completely when finished smoking. The resident is able to communicate the reason oxygen must always be shut off prior to lighter use and the resident is able to communicate the risks associated with smoking. She has the cognitive ability revealed the resident may smoke independently or with set up. The resident was assessed not to need smoking aides such as aprons or a cigarette holder. There was no indication on the smoking evaluation if the resident may or may not maintain her own smoking materials. Review of Resident #102's care plan initiated on 8/17/23 revealed [Resident #102] desires to smoke. Resident has been assessed as able to smoke with supervision. Her goal included Resident will demonstrate safe smoking practices thru the next review date. Interventions included Maintain smoking materials in designated area. Provide assistance with lighting cigarette. Apply/remove smoking apron. Observe for decline in hand dexterity; assist to hold cigarette as needed. And Inform resident of smoking cessation options upon resident request prn [as needed]. The care plan dated 10/21/23 revealed [Resident #102] exhibits the following behaviors AEB [as evidenced by] smoking inside the facility in the room. [Resident #102] aware of the smoking policy and chose to deviated [sic] from it. The goal included, [Resident #102] will followed [sic] the facility smoking through the next review date. Interventions included Approach resident in a calm manner and explain actions. Intervene as needed to protect the rights and safety of resident and others: remove from situation as able. Provide positive reinforcement for successful interactions/efforts. Request psychiatric consult as needed. Update physician of increase in presence or severity of behaviors as indicated. The care plan dated 10/27/23 revealed Resident Choices: Resident has made the following choice(s) regarding his/her care: She uses oxygen and still prefers to smoke, She do [sic] not follow the smoking policy and refuses to wear smoking apron, which puts her at an increased risk for self-arm [sic]. Resident refuses to keep nasal canula in designated oxygen tubing bag. The goal included, Resident will verbalize understanding of potential risks and benefits associated with his/her choices. The interventions included, Continue to encourage resident to wear smoking apron for smoking safety. Honor resident choices. Monitor resident for changes in condition r[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to utilize the Quality Assessment and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to prevent continued accidents and hazards related to smoking safety precautions, for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of 44 residents on the facility residents who smoke list. The facility failed to ensure the safety of all 229 residents in the facility as a result of the failure. On 9/22/23 at 5:11 p.m. Resident #61 was found smoking (alleged) marijuana in an unauthorized smoking area by the Nursing Home Administrator. On 10/21/23 at 4:03 a.m. the facility's fire alarm was triggered when Resident #102 was able to smoke in her room, unsupervised, causing her mattress, privacy curtain, and oxygen concentrator to catch on fire. Staff extinguished the fire, the fire department, and Emergency Medical Services (EMS) were called, residents on the same hallway as Resident #102 were evacuated. Resident #102 sustained a 1st degree burn to her left forearm and shortness of breath due to smoke inhalation. On 10/21/23 Resident #102 was transferred to the hospital for evaluation and treatment. On 10/24/23 at 4:59 p.m. Resident #61 was found by the Nursing Home Administrator smoking in a non-smoking area with his oxygen tank on his wheelchair. Observations conducted on 11/27/23, 11/28/23, and 11/29/23 revealed residents had unsecured smoking materials on their person, were seen lighting other resident's cigarettes on the smoking patio in front of the facility staff and were smoking in non-smoking areas on the facility property. The facility had no effective process in place to ensure residents received smoking safety devices. The facility lacked a functioning process for supervised smoking times. The likelihood of serious physical harm or death to all 229 residents in the facility as a result of the facility's failure to ensure the improvement in safety after life threatening smoking events occurred resulted in the in findings of Ongoing Immediate Jeopardy as of 9/22/23. Findings included: An interview was conducted on 12/1/23 at 3:48 p.m. with Staff R, Assistant Nursing Home Administrator/Risk Manager, and the DON (Director of Nurses). The DON stated the only Performance Improvement PLan (PIP) the facility had in place was the smoking PIP. She stated the quality indicators were education, care plans, residents with oxygen have care plans, and all smoking supplies stored appropriately. The DON stated the PIP started in October 2023. Staff R and the DON stated the PIP had not been successful in ensuring safe smoking and the monitoring of smoking. The DON said the facility was holding daily Ad Hoc meetings to review the audits, but they were unable to find the sign in sheets. The DON stated the facility had not had another QAPI meeting to review the smoking PIP and the meeting was supposed to be on Tuesday, 11/28/23. The DON confirmed the last QAPI meeting was held in October 2023. 1. A review of the admission Record showed Resident #61 was initially admitted to the facility on [DATE] with diagnoses to include burn of unspecified degree of multiple sites of head, face, and neck, COPD [chronic obstructive pulmonary disease], respiratory failure, major depressive disorder, anxiety disorder, muscle weakness, and lack of coordination. Review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section J, Health Conditions showed Resident #61 had shortness of breath or trouble breathing when lying flat. A review of the Order Summary Report with active orders as of 12/01/23 revealed the following orders: (10/24/23) oxygen 2 liters per minute per nasal cannula as needed for shortness of breath and/or to keep oxygen sats above 92% (concentrator only; no portable oxygen tanks)- every shift for shortness of breath/decreased oxygen saturation related to respiratory failure, unspecified whether with hypoxia or hypercapnia, COPD with acute lower respiratory infection, and no tanks in the smoking courtyard and (06/12/23) may go LOA without a responsible party. The Treatment Administration Record for October 2023 showed oxygen 2 liters per minute per nasal cannula as needed for shortness of breath with a start date of 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record also showed oxygen 2 liters per minute via nasal cannula as needed for shortness of breath with a start date of 10/21/23 and discontinued on 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record for October 2023 showed an order for oxygen 2 liters per minute every shift with a start date of 06/23/23 and discontinued on 10/13/23. Oxygen was administered each day and every shift. The Weights and Vitals Summary for oxygen saturations showed the last oxygen saturation was checked on 09/13/23 while the resident was on oxygen via nasal cannula. Review of a Progress Note dated 10/24/23 revealed Resident #61 was witnessed smoking in a non-smoking area with oxygen tank on wheelchair. The resident had a history of noncompliance with smoking. He was to only use a concentrator for Oxygen supplementation. No more portable oxygen tanks to be given for safety purposes due to resident's noncompliance. Review of a Progress Note dated 09/22/23 revealed the resident was smoking (alleged) marijuana in an unauthorized area of the facility. The resident was informed of the facility smoking policy and told if he does it again, he will have to transfer to another facility. The Smoking Evaluation dated 10/21/23 showed Resident #61 used tobacco/nicotine products. He smoked cigarettes. The resident had the cognitive ability to smoke safely, physical dexterity to smoke safely, visual ability to smoke safely, and had the physical ability to smoke safely. The evaluation showed Resident #61 was able to light a cigarette safely with a lighter, he smokes safely, he utilizes ashtrays safely and properly. The resident was able to extinguish the cigarette safely and completely when finished smoking, communicate the reason oxygen must always be shut off prior to lighter use, and communicate the risks associated with smoking per the evaluation. Based on the evaluation, Resident #61 must be supervised by staff, volunteer, or family member at all times when smoking. The statement resident need for safe smoking aide was left blank. The resident must request smoking materials from staff. Intervention had been reviewed. Resident/ resident representative / family have been informed of smoking policies/procedures and Care plan has been reviewed/updated were checked. The form was completed by Staff C, Assistant Director of Nursing. The care plan related to smoking initiated 09/22/23 revealed a focus area to include Resident #61 desires to smoke. He had been assessed as able to smoke with supervision. The goal showed the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices through the next review date of 12/14/23. Interventions included accompany resident to designated smoking area and provide supervision. On 12/01/23 at 11:26 a.m., the Director of Nursing (DON) stated Resident #61 was admitted into the facility with burns from smoking while using oxygen. He had COPD and respiration evaluations were done upon admission and oxygen saturations should be monitored one time per day or every shift. The doctor changed the orders for oxygen from scheduled to as needed because Resident #61 goes outside and smokes while wearing the nasal cannula with the oxygen tank on the wheelchair. The staff would have to go out and get him and take him back to his room because he would be noncompliant with smoking. When the doctor changed the order to as needed for the oxygen, she would expect to see oxygen saturations being monitored at least every shift. There should be ongoing monitoring because Resident #61 had an order for oxygen as needed, and he smokes. The DON stated he had an order to monitor oxygen saturations. She confirmed the last oxygen saturation was checked in September. The DON stated that was not her expectation and there could be some negative effects because he was not being monitored as he should be for oxygen saturations. On 12/01/23 at 2:08 p.m., Staff BB, Resident #61's Physician, stated the resident does not want to hear anything you have to say. She last saw him on 10/30/23 and she talked to him about smoking issues. They were concerned about the time he spent on the smoking patio wearing the oxygen with the portable oxygen tank on the wheelchair. She said she discontinued the continuous oxygen but Resident #61 would just put himself on the oxygen when he came back from smoking. 2) Review of Resident #102's admission Record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Her medical diagnoses include but are not limited to, tobacco use, acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease with (acute) exacerbation, personal history of pulmonary embolism, emphysema, need for assistance with personal care, muscle weakness, essential tremor, metabolic encephalopathy, pleural effusion, cognitive communication deficit, dysphagia, oropharyngeal phase, other specified arthritis, unspecified abnormalities of gait and mobility, chronic pulmonary embolism, anxiety disorder, and major depressive disorder. Review of Resident #102's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 15 out of 15 indicating no cognitive impairments. An interview was conducted with Resident #102 on 11/27/23 at 9:59 a.m. The Resident was observed to be in her room, sitting in her wheelchair on 3 liters of oxygen via nasal cannula. The resident was observed to have a small circular hole with black edges on her upper right thigh of her pants. The resident said her pants came that way. The resident said the staff keep her smoking materials and they stick to the smoking schedule. She said she takes off her oxygen when she smokes, and she does not use an apron when she smokes. Review of Resident #102's Smoking Evaluation dated 10/21/23, completed by Staff C, ADON, revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, does not have the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is not able to light a cigarette safely with a lighter, the resident does not smoke safely (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). The resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish a cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the resident is able to communicate the risks associated with smoking. Summary review: Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. Indicate resident need for safety smoking aides: resident must wear smoking apron at all times. Maintenance of smoking materials: Resident must request smoking materials from staff . Additional Comments: Resident refused smoking apron. Review of Resident #102's Resident/Family Tool dated 10/21/23, completed by Staff C, ADON, revealed the identified learner was the Resident. She understands basic information. Her readiness to learn is accepting. There are no barriers to learning. Education Needs safety and smoking policy. Education Record: Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters[sic] and or vape pens). Documentation of Topic, Instruction, and Additional information: Resident educated to the facility smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (e.g., cigarettes, lighters). Resident cannot smoke near any combustible items such as oxygen tanks & concentrators. Informed resident that per smoking evaluation, she meets the requirements for wearing a smoking apron s/t[sic] incident resulting in a fire after she dropped a cigarette. Resident informed that if smoking policy is violated again, she will be subject to discharge. Resident verbalized understanding & agreement with everything, except smoking apron. Resident stated she will only smoke in designated area, but she doesn't want an apron. Resident verbalized understanding of personal safety risks r/t [related to] wearing apron during smoking breaks. Review of Resident #102's physician orders revealed an order with a start date of 8/13/2023 and no end date of Oxygen at 2 liters/minute via- Nasal cannula every night shift for Respiratory Distress. An order started on 11/10/23 without an end date to Cleanse BURN TO LEFT ARM with normal saline--Gently pat dry--Apply Xeroform to wound--Wrap with kerlix--Secure with tape. Change daily on 3-11 shift. Review of Resident #102's November treatment administration record (TAR) revealed the order was completed as ordered. Review of Resident #102's Narrative Nurses note dated 10/21/23 at 2:01 p.m. revealed, At around 0403 [4:03 a.m.] Smoke alarm sounded. Writer [sic] witnessed smoke and fire in resident's room. Resident was evacuated along with others while code red and 911 were called. Fire was put out with fire extinguisher. Police and fire department arrive [sic] and assisted staff member to evacuate the wing. Per nurse, Resident has burn to her left upper extremity and complaining of difficulty breathing s/p [status post] smoke inhalation. Resident left the facility with O2 [oxygen] via non-re-breather mask with 911. Resident reported to 911 that she was smoking in the room. Assigned nurse to call MD [Medical doctor] and Family member for notification. Review of Resident #102's change in condition dated 10/21/23 revealed At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure: BP 110/64, 10/21/2023 05:03 a.m. Position: Sitting l (left)/arm Pulse: P 88, 10/21/2023 4:05 p.m. Pulse Type: Irregular, chronic RR: R 32, 10/21/2023 5:06 a.m. Temp: T 97.6, 10/21/2023 5:05 a.m. Route: Forehead (non-contact) Weight: W 97.0 lb., 10/5/2023 10:27 a.m. Scale: Mechanical Lift Pulse Oximetry: O2 94 %, 10/21/2023 5:05 a.m. Method: Oxygen via Nasal Cannula .Nursing observations, evaluation, and recommendations are Resident was assess for burns due to her mattress burning . A Narrative Nursing note dated 10/21/23 at 5:54 p.m. revealed PT [patient] returned from hospital with new order for Keflex 500 mg daily. On 10/21/23 at 6:00 p.m. the Narrative Nursing note revealed Resident returned to facility from ER [emergency room] at 1738 [5:38 p.m.]. Resident sent out for burns and dyspnea [difficulty breathing] s/p [status post] smoke inhalation from fire incident earlier today. Resident violated smoking policy by smoking in her room w/ [with] oxygen concentrator present, later resulting in a fire. Resident now returning w/ pressure dressing to left forearm and gauze dressing to right posterior forearm. New skin tear noted under the latter dressing. VSS [vital signs stable], but resident was noted to still have some respiratory discomfort. HOB [head of bed] elevated and Nasal Canula [sic] on 2 LPM [liters per minute], which helped alleviate shortness of breath. During Auscultation, breath sounds were noted to be diminished. Apical pulse normal and regular. Resident did verbalize having some pain. Pain medication given by nurse on duty after assessment to ensure safety of narcotic administration. Resident was then educated on smoking policy and the importance of adhering to it. Resident was apologetic and verbalized agreement and consent w/ complying to smoking policy going forward. Informed resident that smoking re-evaluation resulted in her qualifying for a smoking apron during smoking breaks for safety purposes. Resident stated her refusal to wear apron, as she does not agree with its necessity. Resident educated on the benefits of wearing apron while smoking. Resident verbalized understanding of personal safety risks if she does not wear apron but still stated that she will not wear it. Psychology/Psychiatry consult placed for follow up s/p [status post] incident. On call physician notified of resident's return, present status/condition, new dressing to burn, and new order for prophylactic Keflex s/t [sic] to right forearm burns. Resident comfortable and sleeping in her bed at this time. Review of Resident #102's admission Nursing Comprehensive Eval dated 8/4/23 revealed a smoking evaluation to include, the resident uses tobacco/nicotine products, she uses cigarettes (non-electronic), the resident has the cognitive ability to smoke safely, has the visual ability to smoke safely, physical dexterity to smoke safely, and the physical ability to smoke safely. 02b. Resident Observation She is not able to light a cigarette safely with a lighter. She smokes safely, she utilizes the ash tray safely and properly. She is able to extinguish a cigarette safely and completely when finished smoking. The resident is able to communicate the reason oxygen must always be shut off prior to lighter use and the resident is able to communicate the risks associated with smoking. She has the cognitive ability revealed the resident may smoke independently or with set up. The resident was assessed not to need smoking aides such as aprons or a cigarette holder. There was no indication on the smoking evaluation if the resident may or may not maintain her own smoking materials. Review of Resident #102's care plan initiated on 8/17/23 revealed [Resident #102] desires to smoke. Resident has been assessed as able to smoke with supervision. Her goal included Resident will demonstrate safe smoking practices thru the next review date. Interventions included Maintain smoking materials in designated area. Provide assistance with lighting cigarette. Apply/remove smoking apron. Observe for decline in hand dexterity; assist to hold cigarette as needed. And Inform resident of smoking cessation options upon resident request prn [as needed]. The care plan dated 10/21/23 revealed [Resident #102] exhibits the following behaviors AEB [as evidenced by] smoking inside the facility in the room. [Resident #102] aware of the smoking policy and chose to deviated [sic] from it. The goal included, [Resident #102] will followed [sic] the facility smoking through the next review date. Interventions included Approach resident in a calm manner and explain actions. Intervene as needed to protect the rights and safety of resident and others: remove from situation as able. Provide positive reinforcement for successful interactions/efforts. Request psychiatric consult as needed. Update physician of increase in presence or severity of behaviors as indicated. The care plan dated 10/27/23 revealed Resident Choices: Resident has made the following choice(s) regarding his/her care: She uses oxygen and still prefers to smoke, She do [sic] not follow the smoking policy and refuses to wear smoking apron, which puts her at an increased risk for self-arm [sic]. Resident refuses to keep nasal canula in designated oxygen tubing bag. The goal included, Resident will verbalize understanding of potential risks and benefits associated with his/her choices. The interventions included, Continue to encourage resident to wear smoking apron for smoking safety. Honor resident choices. Monitor resident for changes in condition related to choices. Notify physician of resident choices that are contrary to physician orders. Provide education to resident/responsible party related to choices that are not congruent with physician orders, industry standards or acceptable practices in the skilled nursing facility and the risks involved with their choices. Staff to continue to remind [Resident #102] of the facility smoking policy and redirect her as needed. A phone interview was conducted with Resident #102's Advanced Registered Nurse Practitioner (ARNP) on 12/1/23 at 3:05 p.m. She said she was made aware the resident smoked in her room and caused a fire in the building. She said the resident went to the hospital and returned so quickly that they sent her back to the hospital for monitoring because they were still cleaning everything up. It was a mess. The ARNP said Resident #102 had a 1st degree burn to her left arm that was getting better. She was being seen by wound care and having treatments. When she went to the hospital, they dressed her burn and gave her antibiotics which she continued when she came back to the facility. I was not aware that she needs a smoking apron and refuses it but I know she refuses everything including pharmacological treatment. The day after the fire I did offer smoking cessation options, but she declined it and I continue to offer it to her . 3) Review of Resident #131's admission Record revealed she was admitted on [DATE]. Review of her medical diagnosis included but are not limited paraplegia, major depressive disorder, schizoaffective disorder, and muscle weakness (generalized). Review of Resident #131's Quarterly Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairments. An interview was conducted with Resident #131 on 11/28/23 at 7:50 a.m. The resident said she kept her cigarettes and lighter on her, but she may start turning them in at 4:00 p.m. so they know she wasn't sleeping with them. Sometimes when cigarettes are kept in the box [secured smoking cart], they get stolen but if people want some of my cigarettes that's fine, they can have them. So, I should start turning them in at night. Review of Resident #131's Smoking Evaluation dated 10/21/2023, completed by Staff C, Assistant Director of Nursing (ADON) revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, Has the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is able to light cigarette safely with a lighter, the Resident smokes safely. (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). Residents utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the Resident is able to communicate the risks associated with smoking. Summary review: Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. Maintence of smoking materials: Resident must request smoking materials from staff. Review of Resident #131's Resident/Family Education Tool V2 dated 10/21/23 revealed the identified learner was the Resident . Outcome of Education Session verbalizes understanding. Documentation of Topic, Instruction, and Additional information: Resident educated to the facility smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters and or vape pens). Resident cannot smoke near any combustible such as oxygen tanks and concentrators. Review of Resident #131's care plan dated 8/3/23 revealed [Resident #131] desires to smoke. Resident has been assessed as able to smoke with supervision. Resident prefer [sic] not to follow the smoking policy AEB [as evidenced by]: She[sic] is smoking in non-smoking courtyard. The goals included Resident will demonstrate safe smoking practices thru the next review date and Resident will adhere to the smoking policy daily thru the next review date. Intervention included Remind and encourage resident to follow smoking policy. Maintain smoking materials in designated area. Accompany resident to designated smoking area and provide supervision. 4) Review of Resident #324's admission Record revealed he was admitted to the facility on [DATE]. His medical diagnoses included but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, aphasia, major depressive disorder, weakness, and homelessness. Review of Resident #324's admission MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 15 out of 15 indicating the resident is cognitively intact. Review of Resident #324's admission Nursing Comprehensive Eval dated 11/8/23 revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, has the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is able to light cigarette safely with a lighter, the Resident smokes safely. (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). Resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the Resident is able to communicate the risks associated with smoking. Summary of Review: Resident must be supervised by staff, volunteer, or family member at all times when smoking. And the resident must request smoking materials from staff. Resident/resident representative/family have been informed of smoking policies/procedures . Review of Resident #324's care plan dated 11/9/23 revealed [Resident #324] desires to smoke. Resident has been assessed as able to smoke per facility policy with supervision. The goal included Resident will adhere to the smoking policy daily thru the next review date. The interventions included Maintain smoking materials in designated area. Accompany resident to designated smoking area and provide supervision. Provide redirection if resident is observed in any unsafe smoking practices. Seek the assistance of managers/supervisors if needed. An interview was conducted on 12/1/23 at 3:26 p.m. with the Director of Nursing (DON). She said residents sign a smoking policy upon admission because it is part of the admission packet. She confirmed Resident #324 did not have a signed smoking policy upon admission but he does now. 5) Review of Resident #184's admission Record revealed he was admitted to the facility on [DATE]. His medical diagnoses include but are not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, alcohol abuse, tobacco use, cellulitis, personal history of methicillin resistant staphylococcus aureus [MRSA] infection, muscle weakness (generalized), need for assistance with personal care, other dysphagia, and other speech disturbances. Review of Resident #184's Quarterly MDS dated [DATE], Section C, Cognitive Patterns, revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. Review of Resident #184's Smoking Evaluation dated 10/21/23, completed by Staff C, ADON, revealed the resident smokes tobacco products, has the cognitive ability to smoke safely, has the visual ability to smoke safely, has the physical dexterity to smoke safely, and has the physical ability to smoke safely. The resident is able to light cigarette safely with a lighter, the Resident smokes safely. (Does not allow ashes or lit material to fall while smoking, inhaling, or holding item. Remains alert and aware while smoking. Does not forget he/she is smoking or fall asleep holding item. Does not endanger self or others while smoking. Does not burn furniture, clothing, skin, self, or others. Turns oxygen off prior to lighting cigarette. Smokes only in designated areas). Resident utilizes ashtray safely and properly. (Gets ashes into ashtray. Does not cause/allow sparks or lit tobacco to fall anywhere but into ashtray.) Resident is able to extinguish cigarette safely and completely when finished smoking. (If using an ashtray, crushes lit material out completely. If using a self-extinguishing ashtray, deposits lit material correctly). Resident is able to communicate reason oxygen must always be shut off prior to lighting cigarette. And the Resident is able to communicate the risks associated with smoking. Summary of Review A. Based on resident evaluation, indicate need for assist with smoking: Resident must be supervised by staff, volunteer, or family member at all times when smoking. And the Resident must request smoking materials from staff. Review of Resident #184's Resident/Family Education Tool V2 dated 10/21/23 revealed the identified learner was the Resident. Understands basic information. Readiness to learn is accepting. There are no barriers to learning. Education Needs safety and smoking policy. Education Record: Resident educated to the smoking policy. Resident informed that they are not permitted to store any smoking paraphernalia in their rooms (cigarettes, Lighters [sic] and or vape pens). Resident cannot smoke near any combustible such as oxygen tanks and concentrators. Review of Resident #184's care plan initiated on 5/2/23 revealed [Resident #184] desires to smoke. Resident has been assessed as able to smoke with supervision. His goal included Resident will demonstrate safe smoking practices thru the next review date. His interventions included Maintain

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to develop and implement an effective policy and procedure to address smoking safety and fire hazards for 14 residents (#114, #96, #102, #198, #131, #188, #324, #162, #184, #191, #113, #57, #68, and #61) out of 14 residents sampled for smoking safety out of 44 residents on the facility residents who smoke list. On 9/22/23 at 5:11 p.m. Resident #61 was found by the Nursing Home Administrator smoking (alleged) marijuana in an unauthorized smoking area of the facility. On 10/21/23 at 4:03 a.m. Resident #102, who was on oxygen, was permitted to keep smoking materials at the bedside and as a result Resident #102 was harmed when she smoked in bed on 10/21/23 and started a fire inside the facility. Resident #102 burned herself on her left arm and suffered shortness of breath due to smoke inhalation and was transferred to the hospital for evaluation and treatment. The event endangered all residents in the facility. On 10/24/23 at 4:59 p.m. Resident #61 was found by the Nursing Home Administrator smoking in a non-smoking area with his oxygen tank on his wheelchair. Observations conducted on 11/27/23, 11/28/23, and 11/29/23 revealed residents had unsecured smoking materials on their persons, were seen lighting other resident's cigarettes on the smoking patio in front of the facility staff and were smoking in non-smoking areas on the facility property. The likelihood of serious physical harm or death to all 229 residents in the facility as a result of the facility's failure to develop, implement, and enforce a smoking safety policy resulted in the findings of Ongoing Immediate Jeopardy as of 9/22/23. Findings included: On 11/28/23 from 8:56 a.m. to 9:47 a.m. smoking observations were conducted on the main smoking patio of the facility. Staff O, Certified Nursing Assistant (CNA), was present for the observations. A total of nine residents were observed entering and leaving the main smoking patio during the observations. Staff O, CNA, stated he was the smoking aide but he was not the usual smoking aide. The following observations were noted: At 8:56 a.m. Resident #114 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:10 a.m. he left the smoking area and did not turn in his cigarettes or lighter to the smoking aide. At 8:59 a.m. Resident #96 pulled a cigar pack and a lighter out of his shirt pocket and lit his cigar and placed the package and lighter back in his shirt pocket. At 9:00 a.m. Resident #162 pulled a pack of cigarettes and a lighter out of his pant pocket and lit his cigarette. At 9:08 a.m. he left the smoking patio and did not turn in his cigarettes and lighter. At 9:16 a.m. Resident #102 asked Resident #61 (another resident on the smoking patio) if he could light her cigarette; he said yes, self-propelled his wheelchair closer to Resident #102 and lit her cigarette. Staff O, CNA, was on the smoking patio at this time. At 9:17 a.m. Resident #61 left the main smoking patio with his lighter in his hand. At 9:07 a.m. Resident #198 pulled a pack of cigarettes and lighter out of his shirt pocket, lit his cigarette, and placed them back in his shirt pocket. At 9:14 a.m. he pulled out an electronic cigarette and held it in his hand. At 9:37 a.m. he put his electronic cigarette back in his shirt pocket and left the main smoking patio. Staff O, CNA, held the door open for the resident to exit smoking patio. Resident #198 did not return his smoking materials prior to exiting the smoking patio. At 9:03 a.m. Resident #131 pulled a pack of cigarettes and a lighter out of her pocket and lit her cigarette. At 9:11 a.m. she left the smoking patio and did not turn in her cigarettes or lighter. At 9:17 a.m. she returned to the main smoking patio and pulled out a pack of cigarettes and a lighter out of her jacket pocket and lit her cigarette. At 9:20 a.m. Resident #131 was observed to have lit Resident #188's cigarette with Staff O, CNA, present in the main smoking patio. Resident #188 returned to his chair on the smoking patio. Resident #188 was observed to have black and orange stains on his right pointer finger, right middle finger, and right thumb. Resident #188 said he had those stains from smoking: it's nicotine. The resident was observed to be smoking his cigarette without an apron on and the ash tray in his lap. At 9:30 a.m. Resident #188 left the smoking area. At 9:34 a.m. Staff O, CNA, held the smoking patio door open as Resident #131 left the main smoking patio and she did not turn in her smoking materials. At 9:18 a.m. Resident #324 pulled out a pack of cigarettes and a lighter from his pants pocket and lit his cigarette. At 9:24 a.m. he left the smoking area and did not turn in his cigarettes or lighter to Staff O, CNA. The resident was assisted out of the main smoking patio door by Staff O, CNA. At 9:23 a.m. Resident #162 returned to the main smoking patio and pulled a cigarette pack and a lighter out of his pants pocket and lit his cigarette in front of Staff O, CNA, and put his lighter and cigarettes back in his pocket. At 9:33 a.m. Resident #162 left the main smoking patio pushing Resident #102 in her wheelchair. Staff O, CNA, opened the main smoking patio door to escort them out. Resident #162 did not turn in his smoking materials. At 9:27 a.m. Resident #184 pulled a cigarette pack and a lighter out of his jacket pocket and lit his own cigarette. At 9:47 a.m. he left the smoking patio and did not turn in his smoking materials. An interview was conducted on 11/28/23 at 9:41 a.m. with Staff O, CNA. He said, this is where we store 'some' of the cigarettes, he opened the smoking cart, and there was a total of 20 boxes with names and numbers on them. (Photographic evidence obtained). Review of the facility's Resident Smokers List, undated, revealed there were 44 residents in the facility who smoke. On 11/28/23 at 9:45 a.m. an interview was conducted with Staff K, Activities Director (AD) and Staff O, CNA. Staff K, AD, came to the smoking patio and stated the process for obtaining and stocking the cigarettes in the smoking cart was activity staff's responsibility. Staff K, AD, and Staff O, CNA said residents were supposed to ask for their cigarettes, and get their cigarettes from the locked smoking cart from their personal drawer. They stated, they are supposed to light the residents' cigarettes for them. Staff K, AD said all the residents who smoke were recently educated on the smoking policy. Maybe last month. We can ask them [the residents who smoke] for their smoking materials and some of them will give them up, but most of them will not and we can't force them to give it to us. On 11/28/23 at 8:58 a.m. through 11/28/23 at 9:47 a.m. Staff O, CNA did not attempt to ask residents for their smoking materials prior to exiting the main smoking patio. Staff O, CNA did not attempt to intervene when residents were lighting other residents' cigarettes. Throughout the observation it was observed there were 2 smoking aprons hanging up in the middle of the main smoking patio not in use. The aprons were white and well kept. A resident council meeting was held on 11/28/23 at 10:00 am with eight members of the resident council including the Resident Council President. During the meeting the residents expressed the facility has not done anything about residents smoking in their rooms. The residents said at least eight to nine residents are smoking in their rooms and the facility is not doing anything about it. The residents said they can't go to the courtyard (non-smoking area) because of the residents who smoke. They stated about three weeks ago a resident caught on fire. They stated the facility does nothing about it and the Administrator is aware. The members stated the AD and staff try very hard, but the issue is the residents that go to the store on their own and hide the smoking materials. They stated the floor staff need to do a better job. They stated they would like to go to the courtyard. They said one resident smokes weed so they took his oxygen away. They stated residents smoke reefer in front of other residents and there is no respect for others. The residents said there was a designated area outside for the residents who smoke and a separate area outside for the residents who don't smoke, but the smoking residents take over all areas. On 11/29/23 at 9:59 a.m. an interview was conducted with Staff O, CNA. He said, We had two people who needed a smoking apron on yesterday [11/28/23], one of them you met yesterday, [Resident #188], I asked him if he can put on his apron, and he told me 'No, I don't need it' so that's why I was keeping close to him. After that, the Activities Director talked to him, and he wore his apron the rest of the day. I knew he needed an apron because the Activities Director told me. He and another guy needed them. We can go to the Activities Director if we need something or have a question, because I don't normally do the smoking. An interview was conducted on 11/29/23 at 9:14 a.m. with Staff DD, Activities Assistant. She said, normally she was the one who comes and does the smoking during the smoking times but since the state surveyors were here, the AD had her out on the smoking patio for eight hours a day and administration said she has to do this until the state surveyors leave. During the interview Resident #188 was observed to have a smoking apron on with his ash tray in his lap and ashes on his apron. Staff DD, Activities Assistant said, I know [Resident #188] needs an apron because you see his fingers are brown because he smokes his cigarettes till the end, and he shakes so he needs the apron. I just know what the residents need by looking at them and I am familiar with them because I used to be their CNA. We do not have a book or anything that says what the residents need during smoking, you can just tell. An interview was conducted on 11/29/23 at 4:55 p.m. with Staff DD, Activities Assistant. She said, I used to do just half hour increments for smoking, not all eight hours. At 4:00 p.m. today I had 35 smokers. This is the only smoke area for residents. Those who LOA [leave of absence] don't need supervision. If cigarette and lighter drawer storage is empty the resident is keeping their lighters and cigarettes. An interview was conducted on 11/29/23 at 5:29 p.m. with the Nursing Home Administrator (NHA). He said, The smoking times are posted on the door. You may have noticed that I have had someone out there all day. We have a lot of residents here that are non-compliant, and the smokers are saying that they are smoking in non-smoking areas because no one is out there for them to smoke during the smoking times, which is not true. So, I am trying something new for them, starting mid last week, a staff member stays out there instead of coming just for the smoke times. At first there was a CNA from each unit doing the smoking times but then I noticed that the CNAs will be busy during that time or the CNAs have to leave the floor to go do the smoking times so I incorporated the activities staff in it but then I noticed that the activities staff will just get done with an activity and it will take them two to three minutes to get to the smoking patio and the residents' excuse was staff weren't there on time and that is why they are going to the courtyard to smoke. So, now I have someone scheduled at the smoking patio from 9:00 a.m. to 7:00 p.m. and it should be an activities staff member on the smoking patio. The NHA provided the facility's Designated Smoke Times posted on the door of the smoking patio and said The posting is wrong. From 6:30 p.m. to 7:00 p.m. a CNA from South [NAME] unit is not scheduled to be on the smoking patio, the activities staff are still scheduled to be out on the smoking patio. Then from 9:00 p.m. to 9:30 p.m. a Northwest unit CNA is scheduled to be on the smoke patio and 11:00 p.m.-11:30 p.m. a Central unit CNA is scheduled to be on the smoke patio. The 3:00 p.m.-11:00 p.m. nurse assigns a CNA to the smoking patio, and it is put on the assignment board. Review of the Designated Smoke Times ALL UNITS posting provided by the NHA from the main smoking patio door revealed the following: 9:00AM-9:30AM (ACT) [Activities] 11:00AM-11:30AM (ACT) 1:00PM-1:30PM (ACT) 4:00PM-4:30PM (ACT) 6:30PM-7:00PM (SW) [Southwest] 9:00PM-9:30pm (NW) [Northwest] 11:00PM-11:30PM (CN) [Central] **All Resident Must Comply with Designated Smoking Times and Locations. ** All Residents Must Leave Smoking Materials in Designated Smoke Locker. *All assigned Units/Activities are responsible for taking residents to designated smoking area and monitoring during smoke times. An observation was conducted on 11/29/23 at 5:00 p.m. The AD locked the door of the smoking area and stated the smoking area will be open during the scheduled hours per the designated smoke times posting. On 11/29/23 at 5:48 p.m. the NHA contradicted his previous statement that staff were assigned to be out on the smoking porch continually from 9:00 a.m. to 7:00 p.m. by saying I just reminded everyone of their scheduled times to make sure everyone remembers. He said no one is on the smoking patio now because it's 5:48 . The NHA stopped midsentence, turned around and walked away. On 11/29/23 at 5:52 p.m. the smoking area remained locked. An interview was conducted on 11/29/23 at 5:40 p.m. with Staff FF, CNA. He stated he had done smoking before. He said he knew the residents well and had a good rapport with them. He said Some residents take their cigarettes and lighters to their rooms and others leave them in the box. An interview was conducted on 11/29/23 at 6:00 p.m. with Staff W, CNA. He stated he had done smoking breaks before. He stated I don't know about any aprons; I just go out, they smoke, and I come back in. He also said there had been a couple fires in the building; he just doesn't know which residents they were. An interview was conducted on 11/30/23 at 10:19 a.m. with the Nursing Home Administrator (NHA). He said, There are two resident designated smoking areas, one off the secured unit for the secured unit residents, and one right off of the central unit for all the other residents who smoke. A staff member should be on the secured unit smoking area at all times with the residents. A staff member brings them out to smoke. On the secured unit, that is a little different; the residents will ask you to smoke and that's when they will take them out. There are scheduled times but the residents don't like to follow those times so they will take them out whenever they ask. On October 21st I got a call around 4am I was told [Resident #102] was smoking in her room and the concentrator caught on fire and the fire department had to come out. But the fire was already put out by the time they [fire department] came because it was just the concentrator and the mattress that caught on fire. The resident said she smoked in her room because she felt anxious. So, she was sent out to the hospital. She has a small burn mark on her arm, and she was also on a concentrator [oxygen concentrator] so we sent her to the hospital so they can do an assessment on her to make sure she was all right. The hospital sent her back probably about 30 minutes later. I sent her back to the hospital so I can get the situation taken care of, we were still cleaning up. One of her diagnoses was acute respiratory failure so I felt she should have been there just a little bit longer. She was having difficulty breathing when she was first sent to the hospital. I did not see her when she was first sent to the hospital, I saw her when she came back, and she did not have any soot or burns on her face. We removed the resident from the room, and they removed all the residents in the immediate area, the whole strip of residents on her hallway leading to the nurses station were removed from their rooms and we put them on different units because of the smoke smell. The fire alarms did go off, but the sprinklers did not. Code red was initiated, and they called the fire department. One of the nurses came with the fire extinguisher because there was smoke coming from the oxygen concentrator at that point. The fire department came and checked out everything, EMT [emergency medical team] came to take the resident to the hospital. Then I arrived and we started to clean and open the windows. The equipment that was burned such as the mattress and the concentrator were taken out . Approximately 5 percent of the mattress was burned. The resident was lying on the mattress, and she was wearing her nasal cannula which was attached to the oxygen concentrator and the oxygen concentrator was on. The resident was smoking in her bed with her oxygen on and she dropped her cigarette. The concentrator was not in flames, but it was burning, it was starting to melt. Where the tubing was connected to the concentrator there was a fist-size melted area. The mattress was melted, everyone was saying that it was melted but no flames that I know of. The piece of the nasal cannula that was connected to the concentrator was melted and midway down the nasal cannula from her face was melted together. It was as if she was lying in bed and the piece of the nasal cannula that was by her hand melted together. After the clean-up was done, we offered psych services to all the residents in the immediate area. None of them needed it, they were more upset that I was talking to them waking them up. Later that day I asked them if they were okay, do they know what happened, is there someone they would like to speak with. Of the people I talked to only one person said she knew there was a fire, the other ones didn't know anything. After that we notified the family . of [Resident #102], the [family] lives [out of state], we asked her [the family] how she [Resident #102] got the lighter and she [the family] said she did not know but [Resident #102] has friends down there, so we figured it was one of the other residents because when we asked [Resident #102] who her friends were she was just naming other residents. At that point none of the residents had a change in condition. We started reeducation for all the residents on the smoking policy. That education was started on 10/21/23 and completed 10/21/23. All the smoking residents, we had them sign the smoking policy again because they sign it at admission. The staff were educated on the smoking policy as well as supervision, just supervision, the nurse said she was right there when everything happened but just supervision on the residents at all times as much as possible. The staff member was sitting right in the day room and [Resident #102's] door is the second door from the day room and as soon as she heard the fire alarm, she [NAME] into action . She had just finished her rounds checking all the residents, answering all the call lights and she had just sat down. We also reeducated everyone on the code red drill. Audited resident care plans related to smoking. We added to our daily room audits, which management does, to observed for smoking materials and to notify management. We had all the smoking residents sign an agreement saying they understand they will receive a 30-day discharge notice if they don't remain compliant with the policies. We updated smoking evals for all smoking residents. We have a smoking list of all residents who smoke. Upon admission we ask them if they like to smoke, and we add them to the list. And then for any residents who start to smoke after admission, they [residents] will notify us that they like to smoke, and we will add them to the smoking list. They will usually notify activities because they are the ones who purchase the cigarettes and lighters . [Resident #102] returned with a burn, so she returned with orders to care for her burn. She told me she wasn't in any pain, and she apologized about it. So now [Resident #162] takes her down to the smoking patio to make sure she goes there to smoke. Through the audits we found that residents were going to the courtyard to smoke and that is not a smoking area. We would see them and tell them you know you can't smoke out here, let's go to the smoking patio and they would flick the cigarette out and go to the smoking patio. There is no ash tray or smoking receptacles on the courtyard. Then they would tell me the door wasn't open to the smoking patio and it would be just a couple minutes that the door wasn't open during the smoking time. So as of last night [11/29/23] I have converted 2 staff to be designated smoking aides. The first staff comes in at 9:00 a.m. and leaves at 4:00p.m. and the second one comes at 4:00 p.m. and leaves at 11:30 p.m. On the weekends activity aides will be out there from 9:00a.m.-4:00p.m. then from 4:00p.m.-11:30p.m. the aide who normally does 4:00p.m.-11:30p.m. will cover that until I hire someone. She said she needs the extra hours by working 7 days a week. If she calls out, then we will staff an extra aide to cover. The staff are being educated today [11/30/23] on what each smoking resident needs and what. The smoking safety materials are documented in the care plan, on the Kardex, and I would have to look up exactly where that information is. So, I can tell you [Resident #96] and [Resident #191] and sometimes [Resident #57], I think that's his name, they go out front of the building and smoke. We tell them a million times hey you can't smoke up here, please don't smoke here and they will say oh my bad and they will throw out their butts and go off the property. We tell them every single day when you sign out LOA [leave of absence] that means you are leaving the property. Those guys are signing out LOA telling us they are leaving .I told them please feel free to use the employee smoking area . [Resident #61] is non-compliant with the smoking policy as well. He is one of the residents I caught on the courtyard. I don't think he was smoking a cigarette, by the time you get there close up to him he had something in his hand, but it wasn't lit. I assumed it wasn't a cigarette unless he rolls his own cigarettes. I suspect that has happened two separate times but by the time you get close to him he isn't smoking. The first time I saw him he was on the nonsmoking courtyard. He had the oxygen tank on the back of his wheelchair, the nasal cannula wasn't connected to it and the oxygen tank was not on. I can't recall the date, it could've been a few months ago, it's blending in with all the dates. It was noted that [Resident #61] didn't need a portable oxygen tank so his oxygen was discharged , he was educated, he was asked if we could search his room and he denied. He was issued a 30-day notice for non-compliance of the smoking policy because he was one of the smokers who signed the agreement that he would follow the smoking policy or else he would receive a 30-day notice . He said he wasn't going anywhere, and he wasn't smoking. To my knowledge he was not noncompliant since. We did close the non-smoking courtyard for a couple weeks until we figured out a plan. We opened it back up on 11/21/23 and it was closed down for 3 weeks prior to that. We have issued 30-day notices to 5 or 6 people, and they all refused to leave, and they all refused to sign it as well. We gave them a couple different SNF [Skilled Nursing Facility] options and some ALF's [Assisted Living Facility]. So now we are trying to cater to the situation to make it more welcoming to the smokers. My plan now is to alleviate all excuses they will say why they aren't going to comply to it. My next steps is to see if my regional people can take them to court. I just think the residents are just non-compliant and resistant to the rules. The only feedback I have gotten why they won't smoke on the smoking patio is that the staff are taking too long to get there. When we opened the courtyard back up the effective plan was that activities could stay out on the smoking patio all the time. I feel it is effective except for the residents who sign out and smoke out front. There have been no complaints from the resident; we actually got a thank you from the resident for having it open all the time. The NHA confirmed residents have paraphernalia on them and he confirmed it has the potential to affect all the residents in the facility including residents who do not smoke. The NHA said none of the residents who smoke have any other behaviors except maybe one but she is compliant with her behavior. An interview was conducted on 12/01/23 at 9:11 a.m. with Staff L, Social Services Assistant. She said, I am part of angel rounds. We do it [angel rounds] every day. We ask if there are any issues, check the rooms for trash bags, gloves, anything that needs to be labeled in bags, maintenance of the room check to see if anything needs to be checked up or fixed, check to make sure their call lights are in place. There is a check off sheet we fill out every day. When I do my angel round rooms, I don't think a lot of my residents smoke, but I don't recall seeing smoking materials out. I do see residents in the halls with their smoking materials going to the smoke porch. Review of Bristol Care Center ANGEL ROUNDS form, undated, revealed Daily Check List the sheet did not reveal a section related to smoking materials. An interview was conducted on 11/30/23 at 9:52 a.m. with Staff CC, Receptionist/Accounts Payable. She said, Before residents leave, they have to sign out at the nurse's station first because they have to check their charts to see if they have an LOA order and they call me from the nurses station and let me know. Then the residents have to sign out at my desk as well. [Resident #191] goes out front and smokes. They are supposed to be closer to the end of the road if they smoke. I don't know where [Resident #191] goes when he smokes. I have had education. I just know they are not supposed to be right here [pointed to the front door], they are supposed to be closer to the road .the ones I know who go out to smoke I don't look to see if they have left the property. I just know they have to smoke farther down, by the road; I don't know if that is off the property or not. I have only been here since April. An interview was conducted with the NHA on 11/30/23 at 3:53 p.m. He said he doesn't know how long the smoking issues had been going on. He excused himself from the interview. An interview was conducted with the Director of Nursing (DON) on 11/30/23 at 4:00 p.m. She said, We [facility staff] are not allowed to touch the residents' things and they tell us [facility staff] no when we ask to search their rooms . When the residents are in the hallway with their smoking materials on them, we ask can we have them and they give it up to us, but then the process happens again whether the family brings it to them, or they go on leave and they get it. This has been going on since I have been here in July [2023] that I have seen residents with their smoking materials on them. 1. A review of the admission Record showed Resident #61 was initially admitted to the facility on [DATE] with diagnoses to include burn of unspecified degree of multiple sites of head, face, and neck, COPD [chronic obstructive pulmonary disease], respiratory failure, major depressive disorder, anxiety disorder, muscle weakness, and lack of coordination. Review of Section C Cognitive Patterns of the Quarterly Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. Section J, Health Conditions showed Resident #61 had shortness of breath or trouble breathing when lying flat. A review of the Order Summary Report with active orders as of 12/01/23 revealed the following orders: (10/24/23) oxygen 2 liters per minute per nasal cannula as needed for shortness of breath and/or to keep oxygen sats above 92% (concentrator only; no portable oxygen tanks)- every shift for shortness of breath/decreased oxygen saturation related to respiratory failure, unspecified whether with hypoxia or hypercapnia, COPD with acute lower respiratory infection, and no tanks in the smoking courtyard and (06/12/23) may go LOA without a responsible party. The Treatment Administration Record for October 2023 showed oxygen 2 liters per minute per nasal cannula as needed for shortness of breath with a start date of 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record also showed oxygen 2 liters per minute via nasal cannula as needed for shortness of breath with a start date of 10/21/23 and discontinued on 10/24/23. Oxygen was administered each day and every shift. The Treatment Administration Record for October 2023 showed an order for oxygen 2 liters per minute every shift with a start date of 06/23/23 and discontinued on 10/13/23. Oxygen was administered each day and every shift. The Weights and Vitals Summary for oxygen saturations showed the last oxygen saturation was checked on 09/13/23 while the resident was on oxygen via nasal cannula. Review of a Progress Note dated 10/24/23 revealed Resident #61 was witnessed smoking in a non-smoking area with oxygen tank on wheelchair. The resident had a history of noncompliance with smoking. He was to only use a concentrator for Oxygen supplementation. No more portable oxygen tanks to be given for safety purposes due to resident's noncompliance. Review of a Progress Note dated 09/22/23 revealed the resident was smoking (alleged) marijuana in an unauthorized area of the facility. The resident was informed of the facility smoking policy and told if he does it again, he will have to transfer to another facility. The Smoking Evaluation dated 10/21/23 showed Resident #61 used tobacco/nicotine products. He smoked cigarettes. The resident had the cognitive ability to smoke safely, physical dexterity to smoke safely, visual ability to smoke safely, and had the physical ability to smoke safely. The evaluation showed Resident #61 was able to light a cigarette safely with a lighter, he smokes safely, he utilizes ashtrays safely and properly. The resident was able to extinguish the cigarette safely and completely when finished smoking, communicate the reason oxygen must always be shut off prior to lighter use, and communicate the risks associated with smoking per the evaluation. Based on the evaluation, Resident #61 must be supervised by staff, volunteer, or family member at all times when smoking. The statement resident need for safe smoking aide was left blank. The resident must request smoking materials from staff. Intervention had been reviewed. Resident/ resident representative / family have been informed of smoking policies/procedures and Care plan has been reviewed/updated were checked. The form was completed by Staff C, Assistant Director of Nursing. The care plan related to smoking initiated 09/22/23 revealed a focus area to include Resident #61 desires to smoke. He had been assessed as able to smoke with supervision. The goal showed the resident will adhere to the smoking policy daily and will demonstrate safe smoking practices through the next review date of 12/14/23. Interventions included accompany resident to designated smoking area and provide supervision. On 12/01/23 at 11:26 a.m., the Director of Nursing (DON) stated Resident #61 was admitted into the facility with burns from smoking while using oxygen. He had COPD and respiration evaluations were done upon admission and oxygen saturations should be monitored one time per day or every shift. The doctor changed the orders for oxygen from scheduled to as needed because Resident #61 goes outside and smokes while wearing the nasal cannula with the oxygen tank on the wheelchair. The staff would have to go out and get him and take him back to his room because he would be noncompliant with smoking. When the doctor changed the order to as needed for the oxygen, she[TRUNCATED]